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Practice Guidelines

AAO-HNSF Releases Clinical Practice Guideline

on Acute Otitis Externa
Key Points for Practice DIAGNOSIS
• S ufficient dosing of oral analgesics is essential for Physicians should differentiate diffuse AOE from other
alleviating discomfort and allowing patients to rest and causes of otalgia, otorrhea, and inflammation of the
continue their normal activities.
external ear canal (based on observational studies with
• Topical therapy for uncomplicated AOE is the first-line
a preponderance of benefit over risk), which should
treatment, with no significant differences between
different drug classes. help physicians in determining the appropriate treat-
• If a patient has AOE with a perforated tympanic membrane, ment method. AOE can imitate the appearance of acute
or if perforation is due to tympanostomy tube placement, otitis media and other inflammatory dermatoses such as
then a non-ototoxic topical preparation is advised. eczema, seborrhea, and psoriasis.
• If AOE is complicated by progression beyond the ear Physicians should evaluate patients with diffuse AOE
canal, systemic antimicrobial agents may be warranted. for factors that can change the way the condition is
From the AFP Editors managed. These factors include a nonintact tympanic
membrane, presence of tympanostomy tubes, diabetes
mellitus, immunocompromise, and previous radiother-
Coverage of guidelines from other organizations does not imply
endorsement by AFP or the AAFP. apy (based on observational studies with a preponder-
ance of benefit over risk).
A collection of Practice Guidelines published in AFP is available

A diagnosis of acute otitis externa (AOE) requires sudden Physicians should evaluate patients with AOE for pain,
onset (e.g., within 48 hours) within the past three weeks and the analgesic treatment selected should be based on
of symptoms (e.g., otalgia, itching, fullness, hearing loss, the severity of the patient’s pain (based on well-designed
jaw pain) and signs (e.g., tenderness of the tragus or randomized trials with a preponderance of benefit over
pinna) indicating inflammation of the ear canal. Causes harm). Continued use of an appropriate analgesic at a
of AOE include regular or aggressive removal of cerumen sufficient dose is essential in alleviating discomfort and
(e.g., through cleaning of the ear), which usually acts as allowing patients to rest and to continue their normal
a protectant against moisture and infection; debris from activities. Physicians need to know the appropriate dose,
dermatologic conditions; local trauma; irrigation; and timing, route of delivery, and possible adverse effects to
wearing hearing aids. AOE is more common in persons adequately control a patient’s pain with analgesics. The
living in areas that are warmer with increased humidity, oral route is preferred because of its convenience, ease of
and in persons who live in areas where they spend more use, and low cost. Continued assessment of the patient’s
time in the water (e.g., swimming). pain and how it is being managed is crucial.
Most AOE cases in North America are bacterial. Physicians should not prescribe systemic antimicrobi-
Although topical antimicrobials can be a useful treat- als initially in patients with diffuse uncomplicated AOE,
ment option, oral antibiotics have been shown to have unless the condition has moved beyond the ear canal
limited usefulness. Because there is a variance in man- or if specific indications for systemic therapy are pres-
agement options and because accurate diagnosis of AOE ent (based on randomized controlled trials with minor
is important, the American Academy of Otolaryngology– limitations and a preponderance of benefit over harm).
Head and Neck Surgery Foundation (AAO–HNSF) Topical therapy is the recommended initial treatment for
chose to update its previously released guideline on AOE because of its safety, effectiveness, and exceptional
AOE. This more recent guideline provides information outcomes in comparative studies. With topical therapy,
based on new data. It focuses on patients two years or a highly concentrated antimicrobial can be delivered to
older with diffuse AOE. the infected area; this can be 100 to 1,000 times stronger

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Practice Guidelines

than systemic therapy. Topical therapy should be supple- For patients two years or older, the management
mented with systemic antibiotics if the patient has a con- course for diffuse AOE is as follows:
dition that is associated with increased morbidity; if the •  Analgesics should be prescribed based on the sever-
infection has spread beyond the ear canal into the pinna, ity of the patient’s pain.
skin of the neck or face, or into deeper tissues; or if topi- •  If the condition has extended beyond the ear canal
cal therapy cannot be delivered effectively. or if indications for systemic therapy are present, sys-
Physicians should prescribe topical therapy initially temic antimicrobials active against Pseudomonas aerugi-
for diffuse uncomplicated AOE (based on randomized nosa and Staphylococcus aureus (alone or combined with
trials with some heterogeneity and a preponderance of topical therapy) should be prescribed. If needed based
benefit over harm). If a patient’s tympanic membrane on the underlying condition, other management options
is perforated, including from a tympanostomy tube, should also be provided.
the physician should prescribe a non-ototoxic topical • If the condition has not extended beyond the
preparation. A variety of topical therapies are approved ear canal and no indications for systemic therapy are
by the U.S. Food and Drug Administration for treatment present, the patient should be evaluated for perforated
of AOE. Most options provide antimicrobial activity tympanic membrane or tympanostomy tubes. If either
through an antibiotic, a steroid, or a low-pH antiseptic. is present, topical therapy with a non-ototoxic prepara-
Three meta-analyses determined that topical therapy tion should be prescribed. If neither is present, topical
is an effective first-line option and that there are no therapy based on benefits, cost, adherence, and patient
important differences in outcomes with different drug preference should be considered. Either way, the patient
classes, with quinolones vs. nonquinolones, or with topi- should be evaluated for an ear canal obstruction.
cal therapy alone vs. combination therapy with a steroid. •  If an obstruction is found, an aural toilet should be
Because there are few differences in effectiveness with performed to remove the debris, and a wick should be
most topical antimicrobials and steroids, the patient’s placed if edema prevents administration of the medication.
preference and the physician’s experience are important •  The patient should be counseled about administering
in choosing the treatment method, as are cost, therapy ear drops, regardless of whether an obstruction is present.
adherence, and possible adverse effects. •  All patients should be evaluated in 48 to 72 hours
The delivery of ear drops can be improved by educat- to determine whether there has been any improvement
ing the patient on how to administer them. If the ear in symptoms.
canal is obstructed, the physician should perform an •  If there has been no improvement, then the patient
aural toilet, place a wick, or both (based on observational should be re-evaluated to determine whether another
studies with a preponderance of benefit over harm). The illness is contributing to the AOE. (If found, the illness
medication must be dispensed to the infected area for should be treated.) If no other illness is contributing to
topical therapy to be effective. Delivery of the ear drops the patient’s AOE, administration of the medication, the
can be hampered by poor patient adherence, ineffective patient’s adherence to therapy, and the need to change
administration, or an obstruction (e.g., debris, edema therapy should be evaluated.
closing the canal). Administering the drops can be • If medication administration, patient adherence,
difficult for patients, because it is done by feel. Of the and changing therapy have been evaluated, or if clinical
patients who administer their own ear drops, only 40% improvement has been observed in 48 to 72 hours, the
do it correctly within the first three days. Patient adher- course of therapy should be completed.
ence to ear drops is greater when another person admin- Guideline source: American Academy of Otolaryngology–Head and
isters the drops; therefore, this is the preferred method Neck Surgery Foundation (AAO-HNSF)
for administration when possible.
Evidence rating system used? Yes
If a patient does not respond to initial treatment within
48 to 72 hours, the physician should re-evaluate the Literature search described? Yes
patient to confirm the diagnosis and to exclude other Guideline developed by participants without relevant financial
causes (based on observational studies and a preponder- ties to industry? No
ance of benefit over harm). The physician should evaluate Published source: Otolaryngology–Head and Neck Surgery,
the patient’s adherence to treatment, including observ- February 2014
ing appropriate administration of the ear drops by the
Available at:
patient or another person. If the patient’s symptoms do
not resolve, but the failure of the therapy is not related to Endorsed by the AAFP, September 2014:
administration of the ear drops or microbiologic factors,
this may indicate a comorbidity or incorrect diagnosis. LISA HAUK, AFP Senior Associate Editor ■

736  American Family Physician Volume 90, Number 10 ◆ November 15, 2014